The Journal of Laryngology & Otology (2011), 125, 53 58.

JLO (1984) Limited, 2010 doi:10.1017/S0022215110002100

MAIN ARTICLE

Rigid endoscopic evaluation of conventional curettage adenoidectomy

D REGMI, N N MATHUR, M BHATTARAI
Department of Otolaryngology and Head and Neck Surgery, B P Koirala Institute of Health Sciences, Dharan, Nepal

Abstract
Objectives: To evaluate the results of conventional adenoidectomy, using rigid endoscopy of the nasopharynx, and to establish the role of such evaluation in facilitating complete adenoid removal via the curettage technique. Design : Descriptive rigid endoscopic evaluation of the nasopharynx before and after adenoid curettage, and following subsequent endoscopy-assisted adenoidectomy. Setting : Tertiary referral centre. Patients : Forty-one consecutive children with symptomatic adenoid hypertrophy scheduled to undergo adenoidectomy. Results : Rigid endoscopic evaluation indicated that conventional curettage, used alone, failed to completely remove adenoid tissue from the superomedial choanae and anterior vault in all cases; incomplete removal was also seen in other parts of the choanae (in 67.2 per cent of patients), the eustachian tube opening (63 per cent), the nasopharyngeal roof (61.78 per cent) and the fossa of Rosenmuller (61 per cent). Subsequent rigid endoscopy-assisted adenoidectomy successfully removed the residual adenoid tissue from all nasopharyngeal sites, except the eustachian tube opening in two cases. Conclusion: Conventional curettage adenoidectomy misses a substantial amount of adenoid tissue. Rigid endoscopy-assisted adenoidectomy improves this result by enabling localisation of any residual adenoid tissue. Key words: Adenoidectomy; Endoscopy; Otorhinolaryngologic Surgical Procedures

Introduction Adenoidectomy is a commonly performed procedure in the field of otolaryngology. It has traditionally been conducted using the curettage method. This is a relatively blind technique which risks nasopharyngeal injury and incomplete adenoid removal; indeed, it has been found to completely remove adenoid vegetations in less than 30 per cent of cases.1 In 1992, Becker et al. reported the use of endoscopyassisted adenoidectomy.2 This technique uses a 0, 30, 70 and 120 rigid nasal endoscope of 2.7 or 4 mm diameter. It has the advantages of improved visualisation and magnification, rigidity, superior haemostasis, reduction of unnecessary trauma, complete removal of adenoid tissue, and improved safety. Endoscopyassisted adenoidectomy is generally perceived to be more effective in clearing adenoid tissue, compared with the conventional curettage method, but this has not been objectively assessed. Therefore, we undertook a descriptive, crosssectional study evaluating the nasopharynx of 41 consecutive paediatric adenoidectomy cases, using a 0, 30 and 70, rigid, 4 mm endoscope. The study
Accepted for publication 2 June 2010

aimed (1) to evaluate the role of such endoscopy in assessing the adenoids before and after traditional curettage adenoidectomy; (2) to assess the effectiveness of curettage adenoidectomy performed alone; and (3) to evaluate the possible role of such endoscopy in improving the results of curettage adenoidectomy.

Materials and methods We included in the study 41 paediatric patients undergoing adenoidectomy with or without other surgical procedures (e.g. tonsillectomy or ventilation tube insertion), whose parents were willing to give informed consent. We excluded patients with contraindications for adenoidectomy, and those in whom the rigid nasopharyngeal endoscope could not be navigated up to the nasopharynx. Ethical approval was obtained from our institutions ethical committee. All patients underwent clinical history-taking, and were assessed pre-operatively using relevant, noninvasive investigations such as pure tone audiometry, impedance audiometry and X-ray (using a soft tissue, lateral neck view with open mouth and neck extension).

First published online 18 October 2010

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The nasal cavity was decongested with cotton soaked in 0.05 per cent oxymetazoline. The nasopharynx was inspected via the nasal cavity using a 0, 30 and 70 rigid endoscope (Karl Storz, Tuttlingen, Germany) to assess the extent of adenoid tissue (this was the first endoscopy). The operating surgeon was kept unaware of the findings. Surgery was performed under general anaesthesia with orotracheal intubation, with the patient placed in Roses position. A Boyle Davis mouth gag of appropriate size was inserted. A small French rubber catheter was inserted through the nostril and brought out through the mouth, and the ends were clinched for palatal retraction.3 The operating surgeon assessed the size and extent of the adenoid with the index finger of the dominant hand. The adenoids were removed by conventional curettage. Small tags of lymphoid tissue retained after curettage were removed with punch forceps. Pressure haemostasis was achieved by packing the area with sterile cotton gauze packs soaked in adrenaline (1:100 000), for three minutes unless contraindicated. If adrenaline was contraindicated, sterile gauze packs soaked with saline only were used.4 Thereafter, the patients nasal cavity and nasopharynx were again examined endoscopically, by the same endoscopist as previously, to determine the completeness of adenoid tissue removal at different sites (this was the second endoscopy). If remnant adenoid tissue was seen, it was removed under endoscopic control, and the final result again assessed endoscopically (this was the third endoscopy). Following curettage and endoscopy-assisted adenoidectomy, the volume of adenoid tissue removed was measured using the displacement method (utilising a 25 ml measuring cylinder).

Results Patients mean age standard deviation (SD) was 8.83 2.77 years; most were aged seven to 12 years. The male to female ratio was 1.56:1. The most common symptom was snoring (97.6 per cent), followed by nasal obstruction. Mouth-breathing was
TABLE I PATIENTS CLINICAL FEATURES Clinical feature Patients % Snoring Nasal obstruction Mouth-breathing Sore throat Sleep apnoea Ear ache Hearing loss Nasal discharge Ear discharge Voice change Epistaxis 97.1 95.1 85.6 80.5 29.3 24.4 22 19.5 9.8 4.9 0 n 40 39 35 33 12 10 9 8 4 2 0

seen in 85.5 per cent cases, and a sore throat in 80.5 per cent (Table I). All the patients had enlarged adenoids on X-ray (soft tissue, lateral neck view). The most common surgical procedure conducted was adenotonsillectomy (n = 32), followed by adenotonsillectomy with ventilation tube insertion (n = 6). Isolated adenoidectomy was performed in only one case. In seven cases, both choanae were completely blocked by adenoid tissue, preventing passage of the 4 mm rigid endoscope. In the remaining cases (n = 34), the nasopharynx could be easily accessed with a 0, 30 and 70, 4 mm, rigid endoscope, and the adenoid tissue extent at various nasopharyngeal sites could be studied satisfactorily. Before curettage, adenoid tissue was found to be present in all cases in the nasopharyngeal roof and superomedial choanae. Adenoid tissue was also present in the anterior vault (in 91.6 per cent of patients), other parts of the choanae (84.15 per cent), the fossa of Rosenmuller (77.95 per cent) and the eustachian tube opening (76.45 per cent). The second endoscopy could be easily performed in all cases. Excellent haemostasis was achieved in all patients. In all cases, the curettage technique failed to completely remove adenoid tissue from the superomedial choanae and the anterior vault. Other sites of incomplete removal were (in descending order of frequency) other parts of the choanae (in 67.2 per cent of patients), the eustachian tube opening (63 per cent), the nasopharyngeal roof (61.78 per cent) and the fossa of Rosenmuller (61 per cent) (Figure 1). The curettage method was most successful in removing adenoid tissue from the nasopharyngeal roof; even so, 38.2 per cent of patients had incomplete removal at this site. Thus, further, endoscopy-guided clearance was necessary in all cases to ensure complete removal of adenoid tissue. Data on the success of curettage adenoidectomy are presented in Table II. Endoscopy-assisted adenoidectomy successfully removed the residual adenoid tissue from all nasopharyngeal sites, except for the eustachian tube opening in two cases (Figure 2). Thus, the success rate for complete adenoid remnant removal from the eustachian tube opening, under endoscopic guidance, was 89.4 per cent. For all other nasopharyngeal sites, a 100 per cent success rate was achieved. Data on the success of endoscopy-assisted adenoidectomy are presented in Table III. The mean volume SD of adenoid tissue removed using conventional curettage was 1.74 0.77 ml (range 0.50 3). In addition, endoscopy-assisted adenoidectomy removed a mean volume SD of 0.91 0.34 ml (range 0.5 2). Thus, if endoscopy-assisted adenoidectomy had not been performed, 34.3 per cent of the total adenoid tissue volume would have been retained (this equates to 52.3 per cent of the adenoid tissue volume removed by curettage).

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FIG. 1 Site of residual adenoid tissue (AT) following conventional curettage. L = left; R = right; Cho = other parts of choana; ETO = eustachian tube opening; FOR = fossa of Rosenmuller; SMC = superomedial choana; AV = anterior vault

The mean time SD required to perform the first, pre-operative endoscopy was 3.56 1.58 minutes (range 1 10), while that for the second, post-curettage endoscopy was 8.82 2.15 minutes (range 2 12). Intra-operative complications were noted in two patients, in the form of transient tachycardia while packing with adrenaline-soaked gauze, immediately after curettage adenoidectomy. This resolved upon removal of the pack. One patient developed a reactionary haemorrhage from the tonsillar bed six hours post-operatively; this was managed successfully with bipolar cautery under general anaesthesia.

The patients mean SD hospital stay was 3.76 0.487 days (range 3 5).

TABLE II PATIENT RESULTS FOR CURETTAGE ADENOIDECTOMY AT site N1 N2 AT present at End-1 (n) AT present at End-2 (n) No L Cho R Cho L ETO R ETO L FOR R FOR NP roof L & R SMC L & R AV 34 34 34 34 34 34 34 24 24 34 34 34 34 34 34 34 24 24 27 28 22 27 25 28 34 24 22 9 9 3 5 6 7 13 0 0 Yes 18 19 19 22 19 21 21 24 22 33.3 32.1 13.6 18.5 24 25 38.2 0 0 Complete AT removal (%)

AT = adenoid tissue; N1 = first endoscopy; N2 = second endoscopy; End-1 = pre-operative endoscopy; End-2 = post-curettage endoscopy; L = left; R = right; Cho = other parts of choanae; ETO = eustachian tube opening; FOR = fossa of Rosenmuller; NP = nasopharyngeal; SMC = superomedial choanae; AV = anterior vault

Discussion The objective of adenoidectomy is to remove the hypertrophic adenoid tissue that causes nasal airway obstruction and pathological restriction of nasal airflow. Dissatisfaction with the safety and adequacy of clearance of conventional curettage adenoidectomy has led to the development of alternative techniques, made possible by developments in fibre-optics and endoscopic instrumentation.5 7 The main disadvantage of curettage is that it is a relatively blind technique that may lacerate the choanae and torus tubarius and graze the nasopharyngeal mucosa; it may also merely skim the adenoid bulk, leaving behind obstructing tissue particularly at the eustachian tube openings and intranasal protrusions and high in the nasopharynx.8 A popular alternative to conventional curettage is endoscopy-assisted adenoidectomy the second method employed in our study. Our study was designed to assess the success of conventional curettage adenoidectomy versus endoscopyassisted adenoidectomy in removing adenoid tissue from different nasopharyngeal sites. We also aimed to assess the possible role of rigid endoscopic evaluation in improving the success of conventional curettage adenoidectomy. The first, pre-operative endoscopy could not be conducted in two patients due to bilateral inferior turbinate hypertrophy; these patients were thus excluded from the study. In the remaining cases (n = 41), the adenoid tissue was easily assessable prior to curettage,

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FIG. 2 Site of residual adenoid tissue (AT) following endoscopy-assisted adenoidectomy. L = left; R = right; Cho = other parts of choana; ETO = eustachian tube opening; FOR = fossa of Rosenmuller; SMC = superomedial choana; AV = anterior vault

using a 0, 30 and 70, 4 mm, Hopkins rod rigid endoscope. The anterior vault and the superomedial portion of the choanae were assessed with a 70 Hopkins rod rigid endoscope and a posterior rhinoscopy mirror. Pre-operatively, adenoid tissue was invariably found at the nasopharyngeal roof, followed by the fossa of Rosenmuller (on the left in 73.5 per cent of patients and on the right in 82.4 per cent) and the eustachian tube opening (64.7 per cent on the left and 79.4 per cent on the right). We searched the literature but could not locate any similar studies performed to assess the nasopharyngeal extent of adenoid tissue, prior to performing curettage. In our study, the

TABLE III PATIENT RESULTS FOR ENDOSCOPY-ASSISTED ADENOIDECTOMY AT site N1 N2 AT present at End-2 (n) AT present at End-3 (n) Yes L Cho R Cho L ETO R ETO L FOR R FOR NP roof L & R SMC L & R AV 34 34 34 34 34 34 34 24 24 34 34 34 34 34 34 34 24 24 18 19 19 22 19 21 21 24 22 18 19 17 22 19 21 21 24 22 No 0 0 2 0 0 0 0 0 0 100 100 89.4 100 100 100 100 100 100 Complete AT removal (%)

AT = adenoid tissue; N1 = first endoscopy; N2 = second endoscopy; End-2 = post-curettage endoscopy; End-3 = post endoscopy-assisted adenoidectomy endoscopy; Cho = other parts of choanae; ETO = eustachian tube opening; FOR = fossa of Rosenmuller; NP = nasopharyngeal; SMC = superomedial choanae; AV = anterior vault

adenoid tissue observed in the eustachian tube openings and nasopharyngeal vault correlated well with our patients symptoms of ear ache and snoring, respectively. We expect that the anatomical extent of adenoid hypertrophy would affect its clinical symptomatology. Following curettage adenoidectomy, we used cotton gauze packs soaked in 1:100 000 adrenaline to pack the nasopharynx for three minutes, to achieve haemostasis. Adrenaline packs were not contraindicated in any of our cases. Patients were closely monitored for adrenaline side effects. We encountered transient tachycardia in two cases, which settled after removing the nasopharyngeal pack. Excellent peri-operative haemostasis was achieved in all patients. We did not encounter any immediate post-operative haemorrhage; this is consistent with the results of Teppo et al.9 However, one patient (2.4 per cent) developed a reactionary haemorrhage from the right tonsillar bed six hours post-operatively; this was managed successfully with bipolar cautery under general anaesthesia. A prospective study has shown that the incidence of reactionary haemorrhage is 2 8 per cent.10 Return to theatre for haemostasis was required in 0.5% and 2%.11 13 Thus, our complication rate was within acceptable limits. In the present study, a second nasopharyngeal endoscopy was conducted following curettage adenoidectomy, and we noted that the extent of superomedial choanae and anterior vault adenoid tissue was unchanged from its pre-operative state (as viewed at the first endoscopy). Other sites harbouring retained adenoid tissue included (in descending order of frequency) other parts of the choanae (in 67.2 per cent of patients), the eustachian tube opening (63 per cent), the nasopharyngeal roof (61.78 per

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cent) and the fossa of Rosenmuller (61 per cent). Thus, conventional curettage had not cleared the adenoid tissue completely in even a single case. These observations would have not been possible had we not conducted a second endoscopy after the curettage procedure. Hence, the second objective of our study was fulfilled. Although we assessed all cases with a 70 rigid endoscope and a posterior mirror, we found the superomedial choanae and anterior vault could only be evaluated with a 0 and 30 endoscope, with regards to the extent of adenoid tissue. In addition, these two areas were the most inaccessible sites for conventional curettage removal of adenoid tissue. In the present study, conventional curettage adenoidectomy successfully removed adenoid tissue from other parts of the choanae, the eustachian tube opening and the fossa of Rosenmuller areas in 33, 16 and 24.5 per cent of patients, respectively. By comparison, Bross-Soriano et al. studied 150 patients with an absolute indication for adenoidectomy, in order to evaluate the efficacy of conventional adenoidectomy, using intra-operative endoscopic inspection of the nasopharynx, and to evaluate the need for endoscopyguided revision surgery.1 They found residual adenoid tissue in 107 cases, 45.3 per cent of which involved the pharyngeal part of the eustachian tubes. Our study findings indicate a higher prevalence of residual adenoid tissue across a greater range of nasopharyngeal sites, following curettage adenoidectomy. Although not used in the present study, we believe that adenoid tissue in the superomedial choanae and anterior vault can also be effectively dealt with using a microdebrider or suction diathermy. In the present study, endoscopy-assisted clearance achieved complete adenoid removal in all but two cases. In these two patients, a small tag of adenoid tissue could not be removed from the eustachian tube opening; this would have required very tightly curved, small Blakesley or Takahashi forceps, which were unavailable. Huang et al. treated 15 patients with symptomatic adenoid hypertrophy, using combined conventional and endoscopic adenoidectomy (any residual adenoid tissue was completely removed during an endoscopic revision procedure).6 They concluded that (1) this procedure could completely remove large amounts of adenoid tissue without prolonging the operative time, and (2) the endoscope provided a clear, direct view that enabled the surgeon to remove adenoid tissue accurately, to evaluate and stop bleeding effectively, and to avoid unnecessary trauma. Thus, these authors believed that a combined approach employing both conventional and endoscopic adenoidectomy was an effective and safe method for managing enlarged adenoids. Kulak conducted a similar study of 125 adenoidectomy cases, in which complete removal of adenoid tissue was achieved using an endoscopy-assisted method.14

In the present study, the first, pre-operative endoscopy took 3.56 minutes on average. Curettage adenoidectomy took an average of 9.2 minutes, while the second, post-curettage endoscopy took an average of 8.82 minutes. In comparison, in Cannon and colleagues series of 130 endoscopy-assisted adenoidectomy cases, revision endoscopy was performed to clear residual adenoid tissue following curettage and took less than 5 minutes.15 In the present study, the mean volume SD of adenoid tissue removed via conventional curettage was 1.74 0.77 ml (range 0.50 3), while that removed via endoscopy-assisted adenoidectomy was 0.91 0.34 ml (range 0.5 2). Thus, failure to undertake endoscopy-assisted adenoidectomy would have resulted in retention of 34.3 per cent of the total preoperative adenoid tissue volume (equating to 52.3 per cent of the adenoid volume removed by curettage). The use of an endoscope during adenoidectomy gives the surgeon a clear, direct view, facilitating precise and complete adenoid tissue removal, effective haemostasis, and avoidance of unnecessary trauma Endoscopy-assisted adenoidectomy allows better adenoid tissue clearance, compared with conventional curettage adenoidectomy, by enabling localisation of residual adenoid tissue especially in the superomedial choanae and anterior vault Conventional curettage adenoidectomy may achieve the desired clinical results in patients with adenoid hypertrophy; however, endoscopic evaluation indicates that it fails to completely remove adenoid tissue All our patients were discharged on the third post-operative day, giving a mean hospital stay SD of 3.76 0.487 days (range 3 5). The slightly older age of our patient group could be attributed to parents waiting longer before seeking health care for their child, due to differing attitudes to health care compared with other parts of the world.

Conclusion The use of an endoscope gives surgeons a clear, direct view of the nasopharynx, enabling them to remove adenoid tissue precisely and completely, to control bleeding effectively, and to avoid unnecessary trauma. Endoscopy-assisted adenoidectomy improves the results of conventional curettage adenoidectomy by enabling accurate localisation of residual adenoid tissue, especially in the superomedial choanae and anterior vault areas. Conventional curettage adenoidectomy may achieve the desired result in patients with adenoid hypertrophy;

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however, endoscopic evaluation reveals that it fails to achieve complete adenoid removal and hence is less satisfactory than endoscopy-assisted adenoidectomy. Further research is needed to establish whether anatomically complete adenoid removal leads to real clinical benefit for patients.
References 1 Bross-Soriano D, Schimelmitz-Idi J, Arrieta-Gmez JR. Endoscopic adenoidectomy; use or abuse of the technology? Cir Cir 2004;72:15 19 2 Eiji Y, Lawrence M. Nasal endoscopy, video rhinoscopy and documentation. In: Ananda VK, Panje WR, eds. Practical Endoscopic Sinus Surgery, 1st edn. New York: McGraw-Hill, 1993 3 Gabalski EC, Mattucci KF, Setzen M, Moleski P. Ambulatory tonsillectomy and adenoidectomy. Laryngoscope 1996;106: 77 80 4 Wang DY, Bernheim N, Kaufman L, Clement P. Assessment of adenoid size in children by fiberoptic examination. Clin Otolaryngol Allied Sci 1997;22:172 7 5 Parsons DS. Rhinologic uses of powered instrumentation in children beyond sinus surgery. Otolaryngol Clin North Am 1996;29: 105 14 6 Huang HM, Chao MC, Chen YL, Hsiao HR. A combined method of conventional and endoscopic adenoidectomy. Laryngoscope 1998;108:1104 6 7 Yanagisawa E, Weaver EM. Endoscopic adenoidectomy with the microdebrider. Ear Nose Throat J 1997;76:72 4 8 Koltai PJ, Kalathia AS, Stanislaw P, Heras HA. Power-assisted adenoidectomy. Arch Otolaryngol Head Neck Surg 1997;123: 685 8

9 Paradise JL. Tonsillectomy and adenoidectomy. In: Bluestone CD, Stool SF, Alper CM, Arjmand EM, Casselbrant ML, Dohar JE, Yellon RF, eds. Pediatric Otolaryngology, 4th edn. Philadelphia: Saunders, 2002 10 Drake-Lee A, Stokes M. A prospective study of length of stay of 150 children following tonsillectomy and/or adenoidectomy. Clin Otolaryngol 1998;23:491 5 11 Guida R, Muttucci K. Tonsillectomy and adenoidectomy: an inpatient or out-patient procedure? Laryngoscope 1990;100: 491 3 12 Leighton S, Rowe-Jones J, Knight J. Day case adenoidectomy. Clin Otolaryngol 1993;18:215 19 13 Marshall J, Sheppard I, Narula A. A prospective study of day case adenoidectomy. Clin Otolaryngol 1995;20:164 6 14 Uar C. Endoscopic adenoidectomy. Kulak Burun Bogaz Ihtis Derg 2008;18:66 8 15 Cannon CR, Replogle WH, Schenk MP. Endoscopic assisted adenoidectomy. Otolaryngol Head Neck Surg 1999;121:740 4 Address for correspondence: Dr N N Mathur, Professor, Department of ENT and Head Neck Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, India E-mail: drnnmathur@gmail.com Dr N N Mathur takes responsibility for the integrity of the content of the paper Competing interests: None declared